Evaluation of Cognitive Behavioural Therapy Experience

Evaluation of Cognitive Behavioural Therapy Experience Critically analyse and evaluate your experience of using a cognitive behavioural approach to work on a project of a personal challenge or change, integrating commentary on theory, research and practice. Introduction This work discusses in an analytical and evaluative way my experience of the use of a cognitive behavioural approach towards addressing the personal challenge of being extremely anxious when using personal computers. Firstly, a project summary provides an overview of the situation with references to relevant theory and research. Then the process of cognitive behavioural assessment is illustrated. Next is a discussion of the rationale of the planned interventions and an overall evaluation of the approach. Finally, the application of cognitive behavioural approaches in my work as a psychologist at an NHS psychology centre for adults is provided with some concluding remarks. Project summary My personal challenge is to control my anxiety and dread whenever I have to use a computer. I tend to think of myself as a generally relaxed person unless I have to use a computer, then I become anxious with clammy hands and feel my heart throbbing in my chest. Although I understand that the use of computers is world wide and that using the computer is essential at most workplaces I feel anxious and sometimes sheer panic if I have to use a computer therefore at most times I avoid using a computer. This problem is affecting negatively my work and it is embarrassing to feel computer anxiety in a world full of computers. Literature review Howard Smith (1986) defined computer anxiety as the fear felt towards interacting with a computer that is disproportionate to the actual threat presented by a computer. Tseng, Tiplady, Macleod Wright (1997) observed that approximately 30% 40% of the population is too anxious to use a computer. Recent research by Smith Caputi (2001) emphasises that there is a link between computer anxiety in undergraduate psychology students and debilitating thoughts suggesting further research is needed in order to develop more thorough cognitive models of anxiety. What is anxiety or stress? There is a growing body of knowledge about stress, which has been accumulating since Dr. Hans Selye (Szabo, 1985) who has spent most of his life in anxiety stress research first developed a theory of stress. Many other physicians and psychologists are conducting research on stress, contributing to our understanding and developing promising methods of stress management. The stress researchers are beginning to provide insights into how mind and body work together to produce psychosomatic illness and how this knowledge can be used for prevention. Definition of Stress the General Adaptation Syndrome (in relation to my computer anxiety) As a result of his stress research (Szabo, 1985), Selye developed a definition of stress suggesting that stress is the bodys non-specific response to any demand placed on it whether that demand is pleasant or not and this definition is relevant to my personal challenge of being stressed about using computers. This definition means that the body has a three-stage reaction to stress: (1) alarm, (2) resistance and (3) exhaustion. This three ­-stage response is the stress syndrome called the General Adaptation Syndrome (GAS). (1) In the alarm stage, the body recognises the stressor, which for me is the computer and prepares for fight or flight. My body achieves this state by sending messages from the hypothalamus section of the brain, which stimulates the pituitary gland to release its hormones, which then trigger the adrenal glands to pour out adrenaline. As a result, the rate of my breathing and my heartbeat are quickened, my blood sugar level is raised, my rate of perspiration is increased, my pupils become dilated, and the digestive processes are slowed down. These factors create a huge burst of energy, an increase in muscular strength, and a heightening of vision and hearing natural aids to fight or flight. (2) In the resistance stage, the body must remain alert, leading to the stage of exhaustion. (3) The exhaustion stage means much more than being physically and mentally tired out. When somebody is tired in body and mind, a little extra rest or a change of scene will often quickly restore the person to full vigour; then the person has not reached physiological depletion. When somebody is physiologically exhausted, the body has lost its ability to continue to resist the continuing stress. It has used up its supply of adaptive energy and its defence mechanisms, such as its immune response, are no longer functional. The body is now vulnerable to the stress diseases, including high blood pressure, arteriosclerosis, migraine headaches, gastrointestinal disorders, rheumatoid arthritis, and asthma. The body may even give up during this stage and die. Most physical or emotional stressors do not last long and produce changes in somebody from being in the first and second stage. Usually people go through the first two stages frequently during the course of our lives, as part of our successful adaptation to the many demands of living. I tend to feel alarmed and pressurised to not use a computer being anxious about using the computer and sometimes I get headaches thinking that I should be using computers like everybody else. Positive Stress Versus Distress From what has been outlined above one might think that stress of any king is bad, but that is not the case. According to Selye (1974) there is a need to experience some stress all the time. Even when somebody is asleep our dreams produce stress. I have woken up from nightmares being in front of a huge computer unable to go back to sleep. Thinking about stressors (the computer) and situations I have experienced when my father tried to teach me how to use a computer made me realise that those were the first times I experienced stress to use a computer. This type of stressor is classified by Selye (Szabo, 1985) as damaging and liable to distress, while other stressors such as horse riding I find pleasurable. Situations then are subject to different interpretations. For example using computers is stressful for me, but a delight for others. A key idea that Selye (1974) presents is that what matters is not so much what happens to us, but the way we take it. Herein lays the key to stress ma nagement, which will be considered further later on. Selye (1974) calls the stress that we need for our survival and well-being positive stress. Examples of positive stress include those times when our bodies stress-response mechanisms stimulate us enough to produce a peak performance for an important job or to come through despite a bad cold or a lack of energy. At times, we have performed feats of strength in emergency situations even the seemingly impossible, like single handily moving a huge weight, such as getting a stalled car to the side of the road. Other examples of life situations generating positive stress are going on a first date, taking an examination, and when we are infants, learning to walk. We also get excited and enjoy watching our favourite team in a match. Pleasurable emotions produce positive feelings of exhilaration. For reasons not yet understood, these positive stresses energise us produce healthy relaxation. I would like to be able to feel positive stress and enjoy using computers instead of being distressed. A medium level of pressure and stress leads to peak performance. The performance curve (please see next page) shows that as tension and pressure increase, so our performance increases to a certain point. If pressure continues to increase to a level that is beyond our ability to cope then it soon becomes unhealthy and it can lead to exhaustion and breakdown. It is important to recognise that stress and pressure are different. Pressure is the demands that are placed upon an individual. Pressure itself is not a bad thing and can help to motivate individuals. Stress is the negative experience that results when individuals feel unable to meet the demands upon them. Performance anxiety curve The kind of stress that is bad for us and can be harmful is called distress. Distress results when the stress continues so that we need to keep adapting to it. If the distress continues long enough, it can result in exhaustion. Exhaustion usually affects only parts of the body, a runner in a marathon produces severe stress on her muscles and cardiovascular system which leads to the exhaustion stage, but after a good rest she is back to normal and looking forward to the next race (Malmo, 1959). Computer anxiety Having reviewed the types of stress and the stage responses to stress in terms of neurophysiologic responses, behaviours, thoughts and feelings I find Selye’s (1974) description of the negative stressors best describes my reaction towards using computers. Furthermore, Rosen and Weil claim that one third of college student population feel some anxiety towards using computers (DeLoughry, 1993). Although the literature suggests that I’m not the only one being anxious towards the use of computers I often feel anxious about it and this has a negative influence on how I feel about myself. Assessment What is CBT in relation to assessment and therapy of computer anxiety or stress? Cognitive behavioural assessment is a continuous process of evaluation and monitoring during the length of therapy. According to Kirk (1994) there is a clearly set process to follow aiming to reach agreement with the client about what is the target problem; then to obtain enough detailed information about what factors are responsible for the continuity of the problem and then a process of change with high client involvement. Often clients come for a CBT assessment without any prior knowledge and it is useful to illustrate the main aspects of CBT. Primarily cognitive behavioural therapy assumes that a person’s feelings and behaviour are influenced by his thinking therefore emotional problems are the outcome of debilitating, negative and unrealistic thinking and therapy starts by increasing the person’s awareness of their debilitating thoughts and changing them. CBT is a combination of cognitive therapy, behaviour therapy and learning in way that explains thoughts, feelings and behaviours as the outcome of learning. This learning can be changed so people can change their old learning and gain new ways of thinking, feeling and behaving. Social learning is one approach to learning that postulates people learn by observing what others (role models) do and say (Bandura, 1986). Social learning theory attributes my computer anxiety and stress to when my father was teaching me how to use a computer and he wasn’t patient with my progress. Taking into account that in social learning theory rewards reinforce behaviou r for me then the absence of rewards and the punishment received for not learning by my father to use the computer made me computer averse and anxious. Datttilio Padesky (1990) showed how CBT is a holistic approach because it considers thoughts, feelings, behaviour, social environment, personal history and physiology that influence my computer anxiety – stress. Further, Beck (1995) described CBT as a procedure of guided discovery where the client discovers methods and techniques that will help them to identify and address their debilitating thoughts. The guided discovery works by the client having certain ‘homework’ to complete between CBT sessions in order that he understands which of his thoughts are based on reality he experiments by behaving in different ways that test the reality of his thoughts and he can discover which thoughts are true based on experience instead of mere assumptions. While discovering true thoughts based on his experiential learning the client is encouraged to learn new skills and behave differently in order that his behaviour matches his true thoughts. The assessment of my computer anxiety and stress was done by a behavioural interview and a stress assessment questionnaire (see appendix 1) followed by self-monitoring information. According to Kirk’s (1989) cognitive behavioural assessment framework during the first stage of assessment in the interview the questions I was asked aimed to capture exactly what I feel, think and how I behave when I suffer from computer anxiety – stress. A list of typical situations in which I became anxious and stressed at various degrees was made (see appendix 2). Having discussed my problem then the onset of my anxiety and my stress towards using computers was investigated taking into account the first time I remember being anxious towards using the computer, how it continued and the predisposition to anxiety. My anxiety was measured as a general anxiety – stress concept on Selye’s (1974) classic questionnaire (see appendix 1). I said how my anxiety to use computers started since my father tried to teach me as a teenager with strict rules and impatience. Since then I always felt apprehensive, anxious and sometimes stressed out when having to use a computer especially of others are looking to see how I’m getting on. Aiming to gain enough detail about the content of a problem, cognitive behavioural assessment focuses on the interaction of four ways of responding to a situation: cognitive; emotional; behavioural and physiological (Kirk, 1989). I was asked to remember a recent situation that I felt anxious and/or stressed when having to use a computer and describe what I was thinking (cognitive), feeling (emotional), did or said (behavioural) and any changes on how my body felt. I remember how two days ago I was asked by my tutor to attend a computer class because he thinks if I get to practice using computers I will feel less anxious about them. I became stressed out when the whole class looked at me because my computer was making a loud noise tha t wouldn’t stop because I pressed something. I discovered that although I could remember what I felt (emotional) what I did (behavioural) and how sweaty my hands were (physiological) it was difficult to remember what I was thinking. Because of that my ‘homework’ was to start using a self-monitoring anxiety diary. Self-monitoring information is often used to enhance the effect of behavioural interviewing because it provides the opportunity to describe a problem (my computer anxiety) over time getting specific information about every time I experienced computer anxiety. That makes it also possible to see how often I have computer anxiety. I was asked to record the situation that provoked my anxiety, when it happened and my response using the four systems (thoughts; emotions; behaviour; physiology) as soon as possible after the event for a week. A 0-10 rating scale was also used to measure the intensity of my anxiety (see appendix 3). Beck (1995) describes homework as an essential part of cognitive behavioural therapy and as a way to emphasise its collaborative and self-help principles. This anxiety diary was useful in examining my problem with sufficient detail becoming able to point out what might be holding my problem in place using two ways: a cognitive ABC (Antecedent-Belief-Consequence) model and a behavioural ABC (Antecedent-Behaviour-Consequence) model. Trower et al., (1988) illustrated the cognitive ABC model explaining behaviour in terms of processes that take place between an environmental stimulus and behaviour. According to this model something happens and then the client focuses his attention on it and this is called Antecedent (A). Then the interpretation of what happened occurs in the form of a belief (B) and a consequence (C) which may involve a behaviour and feeling(s) (see appendix 4). On appendix 3 a number of trigger situations are listed during the week of self-monitoring. The analysis of these situations using a cognitive ABC model identified a pattern of common thought processes linking the triggering event and my anxious-stressful consequence (see appendix 4). I also used the behavioural ABC model, based on operant conditioning (Skinner 1974 in Glassman, 2000) to examine why I repeatedly get computer anxiety (see appendix 5). Similarly to the cognitive model there is an antecedent (A) then the behaviour (B) response to the event and the consequence (C) is the outcome of the behaviour. The negative reinforcer I noticed is avoiding the use of computers when asked to use them which then follow negative self-talk about not being able to master the use of a computer. I found this model less useful because of its superficially descriptive nature it does not account for thoughts. Motivation to change Miller (1983) claims that a clients motivation to change is represented as a comparison between the advantages and the disadvantages of changing because both continuing and changing a behaviour is a choice having pros and cons. I’ve done that (see appendix 6). Then I considered Prochaska. DiClemente’s (1986) model of behavioural change where the client develops from an initial precontemplation stage (with no thoughts of change) to contemplation (where the client evaluates advantages and disadvantages of changing); to preparation (where planning and commitment occur) leading to taking action towards behavioural change. If the client takes action(s) to change their behaviour then they progress to maintenance (where efforts focus on long-term change). I discovered that I’m in the contemplation stage having done the comparison between the advantages and the disadvantages of eliminating my computer anxiety it is obvious that advantages are more than the disadvantages. Plan of interventions for eliminating computer anxiety I considered several possible solutions to eliminate my computer anxiety and have discussed with my doctor the possibility of taking medication to free myself from anxiety symptoms (e.g. palpitations) when thinking of computers and when addressing them. I will do: 1. Controlled breathing technique 2. Deep muscle relaxation 3. Set smart goals in order that I get one-to-one help with learning to use computers 4. Progressive relaxation 5. Self-monitoring Evaluation CBT is a very useful approach for dealing with stress because it offers clear methods to support clients by observing, analysing and learning coping skills to deal with anxiety. The use of medication to provide relief from anxiety symptoms can be combined with CBT in order to maximise the short-term outcome. Essential for CBT is the therapeutic relationship to have empathy, trust and respect so that the client does homework between sessions and feels empowered to help themselves. It is beyond the scope of this project to evaluate the therapeutic relationship. However, I certainly developed a self-help attitude and became more aware of my thought, behaviours, feelings and physiology during computer anxiety events having progressed through the Cycle for Change. I need to develop further my motivation in terms of smart goal setting with times, milestone, have a support network and reward myself for achieving milestones and the goal of eliminating computer anxiety. Conclusion Having implemented self-monitoring I discovered that by dominant behaviour is to avoid the use of computers but that does not eliminate my computer anxiety. This is a valuable insight also about the key role my thought processes have in suffering from computer anxiety. The plan to use relaxation techniques; design of smart goals and have one-to-one supportive advice when dealing with computers is what I’ll do in addition to self-monitoring in order to conquer my challenge of computer anxiety. This project provided me with more thorough understanding of CBT assessment and therapy which I will use in my life and at my clinical practice. References Bandura, A. (1986). Social Foundations of Thought and Action: A Social Cognitive Theory. Englewood Cliffs, NJ: Prentice Hall. Beck, J. S. (1995). Cognitive Therapy: Basics and Beyond. New York: Guildford Press. Datttilio, F.M. Padesky, C. (1990). Cognitive Therapy With Couples. New York: Guilford Press. DeLoughry, T. J. (1993). Researchers Say ‘Technophobia May Afflict Millions of Students’, The Chronicle of Higher Education, 28 April, 25-26. Howard, G. S. Smith, R. D. (1986). Computer Anxiety in Management: Myth or Reality? Communications of the ACM, 29, 611-615. Kirk J. (1989). Cognitive behavioural assessment. In Hawton, K. Salkovskis, P. M. Kirk, J. and Clarke, D. M. (1989) editors. Cognitive Behaviour Therapy for Psychiatric Problems. Oxford: Oxford University Press, 13-51. Kirk J. (1994). Cognitive Behavioural Therapy for Psychiatric Problems. Oxford: Oxford medical publications. Malmo, R. B. (1959). Activation: a Neurophysiological Dimension. Psychological Review, 66, 367-386. Miller, W. R. (1983). Motivational Interviewing with Problem Drinkers. Behavioural Psychotherapy, 11, 147-172. Prochaska, J. O. DiClemente, C. C. (1986). Towards a comprehensive model of change. In Miller, W. R. Rollnick, S. Motivational Interviewing: Preparing People for Change. New York: Guilford Press. Selye, H. (1974). The Stress of Life. New York: McGraw-Hill. Skinner, B. F. (1974). About Behaviourism. London: Cape. In Glassman, (2000) Approaches to Psychology. London: Open University Press, 25-47. Smith, B. Caputi, P. (2001). Behaviour and Information Technology, 20,Number 4, 1 July, 9, 265-273. Szabo, S. (1985). The Creative and Productive Life of Hans Selye: a Review of his Major Scientific Discoveries, Experientia, 41, 564–567. Tseng, H. M., Macleod, H. A. Wright, P. (1997). Computer Anxiety and Computerised Versus Paper and Pencil Assessment of Induced Mood Change. Computers and Human Behaviour 13, 305-316. Appendices Contents Appendix 1: Danger Signs and Symptoms of Stress, Selye (1974) Appendix 2: Typical situations that I’m anxious – stressed when using a computer Appendix 3: Anxiety diary Appendix 4: Cognitive ABC model Appendix 5: Behavioural ABC model Appendix 6: Motivational change – advantages disadvantages Appendix 1: Danger Signs and Symptoms of Stress, Selye (1974) The following checklists are not precise enough to provide an accurate assessment of you but they can be a beginning point for reflection. If you have more than two of these physical signs, you may be placing your body under high risk from excessive stress. More than four of the following mental symptoms (or a total of four physical and mental symptoms) also indicate that you are a high-risk candidate from excessive stress. Summary scores Appendix 2: Typical situations that I’m anxious – stressed when using a computer When I: Try to navigate through different programs Have to do something (I don’t know what) because the computer crashes Try to use the keyboard Place the cursor on a program icon to open it Should write an essay on Word Have to use the computer in front of others Attend a class to learn to use the computer Appendix 3: Anxiety diary Appendix 4: Cognitive ABC model Appendix 5: Behavioural ABC model Appendix 6: Motivational change – advantages disadva